Abstract

Problem/Condition: Firearm-related injuries are the second leading cause of
injury-related death in the United States.

Reporting Period: January 1993--December 1998.

Description of the Systems: Data presented in this report regarding nonfatal
injuries are from the National Electronic Injury Surveillance System of the U.S.
Consumer Product Safety Commission. National estimates of nonfatal firearm-related
injuries were derived using weighted data for patients treated in a nationally
representative, stratified probability sample of U.S. hospital emergency departments (EDs). Death
data presented in this report are from CDC's National Vital Statistics System, which
includes information from all death certificates filed in the 50 states and the District of
Columbia. Population data for calculating rates were obtained from the U.S. Bureau of the Census.

Results: During 1993--1998, an estimated average of 115,000 firearm-related
injuries (including 35,200 fatal and 79,400 nonfatal injuries) occurred annually in the
United States. Males were seven times more likely to die or be treated in a hospital ED for
a gunshot wound than females. The proportion of firearm-related injuries that resulted
in death increased from younger to older age groups. Approximately 68% of
firearm-related injuries for teenagers and young adults aged 15--24 years were
from interpersonal violence, and 78% of firearm-related injuries among older persons
aged >65 years were from intentionally self-inflicted gunshot wounds. Black males aged
20--24 years had the highest average annual fatal (166.7/100,000 population) and
nonfatal (689.4/100,000 population) firearm-related injury rates during the 6-year
period. Although 51.4% of intentionally self-inflicted nonfatal wounds were to the head or
neck, 71.8% of unintentional and 45.8% of assault-related nonfatal wounds were to
the extremities. During the 6-year period, estimates are that quarterly fatal
firearm-related injury rates declined 29.3%, and quarterly nonfatal firearm-related injury rates
declined 46.9%. Firearm-related injury rates declined for intentionally self-inflicted, assault,
and unintentional causes.

Interpretation: Data in this report regarding trends in firearm-related injury
rates during 1993--1998 indicate that both mortality and morbidity from gunshot
wounds declined substantially in the United States. However, firearm-related injury continues
to be a public health concern accounting for approximately 31,000 deaths and
64,500 nonfatal injuries treated in hospital EDs in 1998.

Public Health Action: A state-based, national reporting system is needed to track
the incidence, detailed circumstances, characteristics of the shooter and injured
person, and long-term consequences of fatal and nonfatal firearm-related injuries. These
data would be useful for the design, implementation, and evaluation of prevention
programs aimed at reducing the burden of firearm-related injuries in the United States.

INTRODUCTION

Since 1993, firearm-related injuries and deaths have been declining steadily
(1--3). However, in 1998, firearm-related injuries remained the second leading cause of
injury death in the United States (3), accounting for approximately 31,000 deaths.
The majority of these fatal and nonfatal firearm-related injuries result from
interpersonal violence and intentionally self-inflicted gunshot wounds, but approximately
15,000 unintentional gunshot wounds are treated in U.S. hospital emergency
departments (EDs) each year (4). Although firearm-related injuries represent <0.5% of
injuries treated in hospital EDs, they have an increased potential of death and
hospitalization compared with other causes of injury
(5--7). In 1994, treatment of gunshot injuries
in the United States was estimated at $2.3 billion in lifetime medical costs, of which
$1.1 billion was paid by the federal government
(8). These factors emphasize the importance of firearm-related injuries as a public health concern.

This report presents national data to characterize fatal and nonfatal
firearm-related injuries occurring in the United States during 1993--1998 to supplement
previous reports on long-term trends in firearm-related mortality rates
(9,10). Data regarding firearm-related deaths from the National Center for Health Statistics' National
Vital Statistics System (NVSS) are presented beside data regarding nonfatal
firearm-related injuries treated in U.S. hospital EDs from the U.S. Consumer Product
Safety Commission's National Electronic Injury Surveillance System (NEISS). These
data collectively demonstrate that all segments of the U.S. population are affected
by firearm-related injuries and that injury- and violence-prevention efforts are needed
to reduce further the burden of these injuries on society.

METHODS

A firearm-related injury was defined as a gunshot wound or penetrating
injury from a weapon that uses a powder charge to fire a projectile. This definition
includes gunshot injuries sustained from handguns, rifles, and shotguns but excludes
gunshot wounds from air-powered BB and pellet guns.

National estimates of nonfatal firearm-related injuries were calculated using
data collected during 1993--1998 from NEISS of the U.S. Consumer Product
Safety Commission (CPSC). NEISS is a stratified probability sample of hospitals in the
United States that have >6 beds and provide 24-hour emergency care
(11,12). Through an interagency agreement between CPSC and CDC, information regarding all
patients with gun-related injuries treated in NEISS hospital EDs has been collected since
June 1992 (13,14). Nonfatal firearm-related gunshot cases represent those persons
who were alive when discharged from the ED. The majority of deaths from
firearm-related injuries occur at the scene, in route to the ED, or in the ED before hospitalization
(6,13). Each eligible nonfatal case was assigned a sample weight. Sample weights
were summed to provide national estimates of nonfatal firearm-related injuries.

The sampling frame of NEISS remained the same for 1993--1996, and
NEISS consisted of 91 U.S. hospital EDs randomly selected within each of four stratum
(i.e., very large, large, medium, and small*) on the basis of the number of ED
visits annually. In 1997, the sampling frame of NEISS was updated; a stratum was added
for children's hospitals; and the number of NEISS hospitals was increased to 101
(15). During an 8-month overlap in 1997, gunshot cases were collected from both the
old and new NEISS samples. Analysis of weighted data indicated that differences in
the national estimates of firearm-related injuries based on these two samples
were minimal (i.e., <1%) (CDC, unpublished data). These minimal differences indicate
that trend analysis involving estimates of quarterly nonfatal rates during 1993--1998
were not substantially affected by the updated NEISS sample. Therefore, no
statistical adjustments were made to account for the change in the sampling frame.

Fatal firearm-related injuries were from NVSS of CDC's National Center for
Health Statistics. NVSS provides a complete enumeration of all deaths in the United
States (3). For this report, all deaths of residents of the United States with an
International Classification of Diseases,
9th Revision (ICD-9) underlying cause of death codes
of E922.0-E922.9, E955.0-E955.4, E965.0-E965.4, E985.0-E985.4, or E970 were
included (16). Population estimates are from the U.S. Bureau of the Census.

To derive average annual estimates of nonfatal firearm-related injuries,
weighted data for each year during 1993--1998 were summed and divided by 6. To calculate
the average annual rates, the estimates were summed for the 6 years, then divided by
the sum of the population estimates for the same period and multiplied by 100,000.
Similar calculations were made to derive average annual number of deaths and
average annual mortality rates.

To examine trends in nonfatal firearm-related rates by intent, the weighted
cases with undetermined intent (i.e., 14.0% of nonfatal firearm-related injuries during the
6-year period) were allocated to one of three known intent categories:
unintentional, assault/legal intervention, or intentionally self-inflicted injury. Weighted cases
with undetermined intent were allocated within each quarter of each year on the basis
of the weighted distribution of cases with known intent for each respective quarter.
This method of allocation accounted for the quarterly variation in the percentage
of weighted cases with undetermined intent (range: 7.1%--19.2%) and also for
the seasonal variation observed among the cases with known intent. Although
the percentage of firearm-related deaths with undetermined intent was minimal (i.e.,
1.2% of deaths during the 6-year period), these cases were allocated in the same manner
as the nonfatal estimates to maintain consistency. Linear regression was used to
predict the percentage decline in fatal and nonfatal firearm-related injury rates presented
in this report. The 95% confidence intervals calculated for these percentage
declines accounted for the sample weights and stratified survey design.

Race and ethnicity for nonfatal firearm-related cases from NEISS were
obtained from ED records. The majority of cases were reported as either white, black,
Hispanic, American Indian, or Asian. Nonfatal cases reported as white Hispanic were
classified as Hispanic, and those reported as black Hispanic were classified as black.**
Race/ethnicity categories for firearm-related deaths from NVSS were combined in a
similar
manner. For example, deaths specified as black Hispanic (i.e., 462 deaths or 0.2%
of firearm-related deaths during the 6-year period) were classified as black.
Numbers and rates of nonfatal and fatal firearm-related injuries are presented for the
mutually exclusive categories of white non-Hispanic, black, Hispanic, and other or
unknown categories.

National estimates in the tables, figures, and text of this report are
presented without 95% confidence intervals for brevity. However, unstable estimates are noted
if the co-efficient of variation (CV) was >28%. Generalized relative standard error
tables and formulas for both fatal and nonfatal firearm-related injuries are provided for
data users to calculate 95% confidence intervals for specified point estimates (Appendix).

RESULTS

Fatal and Nonfatal Firearm-Related Injuries, Overall and
by Race/Ethnicity, Sex, and Disposition

During 1993--1998, an estimated average of 115,000 firearm-related
injuries occurred annually. Of these, approximately 30% resulted in death. This lethality rate
is substantially higher than all causes of injury combined where <1% of cases were
fatal (Figure 1).

Both fatal and nonfatal firearm-related injury rates were highest among
persons aged 15--24 years; black males in that age group had the highest risk (Figures
2,3; Tables 1--3). Fatal and nonfatal firearm-related injury rates for Hispanics
were generally less than those for blacks, but higher than those for white,
non-Hispanics (Figure 3; Tables 1--3). The firearm-related death rate for males was six times
higher than that for females; the nonfatal firearm-related injury rate for males was
eight times higher than that for females (Tables 1--3). The proportion of persons who
died from firearm-related injuries increased with age (Figure 4). Of those who survived
a gunshot wound and who were treated in a hospital ED, approximately 55%
were hospitalized or transferred, and the other 45% were treated and released (Tables
2--4).

Fatal and Nonfatal Firearm-Related Injuries, by Intent of Injury

The proportion of persons with firearm-related injuries who died from
intentionally self-inflicted gunshot wounds increased with age (Figure
5). For persons of all
ages, the firearm-related suicide rate was four times higher than the nonfatal,
self-inflicted injury rate (Table 5). Firearm-related suicide rates were highest among persons
aged >65 years (Figure 6).

A majority of firearm-related injuries for persons aged 15--44 years were
caused by interpersonal violence (Figure 5). For persons in this age group, for every
firearm-related homicide, 3--4 persons with nonfatal firearm-related injuries were treated
in U.S. hospital EDs (Table 5). Assault-related fatal and nonfatal firearm-related
injury rates were highest among persons aged 15--24 years (Figure
7; Table 5).

Although unintentional injury accounts for <4% of firearm-related deaths,
it accounts for 17% of nonfatal firearm-related injuries treated in U.S. hospital
EDs. Unintentional fatal and nonfatal firearm-related injury rates are highest
among persons aged 15--24 years and decrease consistently with age (Figure
8; Table 5).
For persons aged <14 years, unintentional injury accounts for approximately 40%
of nonfatal firearm-related injuries where the intent of the injury had been
determined (Figure 5).

Nonfatal Firearm-Related Injuries, by Injury Characteristics
and Circumstances of the Incident

Intentionally self-inflicted nonfatal injuries predominantly involved gunshot
wounds to the head or neck (Figure 9; Table
6). In contrast, for firearm-related assaults
and those of undetermined intent, approximately 15% were gunshot wounds to the
head or neck, and >30% were gunshot wounds to the leg or foot. For unintentional
nonfatal injuries, >70% were gunshot wounds to the legs or arms (Figure
9; Table 6). Additionally, >70% of unintentional nonfatal injuries were self-inflicted
(Table 6).
Other characteristics of overall nonfatal firearm-related injuries, in all intent categories, were

 20% were reported to occur in the home;

 approximately 2% were reported as job-related;

 18% were reported to be self-inflicted;

 35% were reported to involve a handgun

 approximately 60% were transported to the ED by ambulance or other
emergency medical services; and

 a majority of injured persons aged
>18 years were never married (Table 7).

Temporal Trends in Fatal and Nonfatal Firearm-Related Injuries

Based on linear regression analysis of quarterly rates, both fatal and
nonfatal firearm-related injury rates declined significantly during 1993--1998. The fatality
rate declined 29%, and the nonfatal rate declined 47% during this period (p < 0.01)
(Figure 10). The extent of the decline in fatal and nonfatal rates varied by intent of injury.
For firearm-related deaths, the suicide rate dropped approximately 15%, compared
with 42% for the homicide rate and 47% for the unintentional rate (Figures
11--13).***
For nonfatal firearm-related injuries, the suicide attempt rate declined 48%,
compared with 49% for the assault rate and 37% for the unintentional rate (Figures
11--13).

DISCUSSION

In this report, data from two national data systems, NVSS and NEISS, were used
to provide a comprehensive 6-year representation of fatal and nonfatal
firearm-related injuries in the United States. These data demonstrate that firearm-related injury
rates steadily declined during 1993--1998, including unintentional, assault-related
and intentionally self-inflicted injuries. Although firearm-related injuries among
teenagers and young adults were predominantly associated with interpersonal violence,
a majority of firearm-related injuries among older adults were intentionally
self-inflicted. Nonfatal injuries that were intentionally self-inflicted predominantly involved
wounds to the head or neck compared with other types of injury that were most often to
the extremities. These self-inflicted gunshot wounds potentially represent more
life-threatening injuries with long-term sequelae
(6). Although black males aged 15--24 years had the highest fatal and nonfatal rates, firearm-related injuries occurred
among all segments of the U.S. population as defined by race/ethnicity, age, and sex.

Although fatal and nonfatal firearm-related injury rates have dropped
substantially during 1993--1998, firearm-related injury continues to be a public health concern.
In 1998, approximately 31,000 U.S. residents died from gunshot wounds, and
another 64,000 were treated for nonfatal wounds in U.S. hospital EDs. In 1998,
firearm-related injuries were the second leading cause of injury death in the United States after
motor-vehicle--related deaths (3). Firearms were associated with 65.9% of homicides
and 57.0% of suicides among U.S. residents. Although the percentage of
firearm-related deaths that were unintentional was limited (i.e., <4% of deaths), approximately
one fifth of nonfatal firearm-related injuries treated in U.S. hospital EDs were unintentional.

Certain limitations are associated with using NEISS data to examine
nonfatal firearm-related injuries in the United States. NEISS only provides national
estimates and does not allow for estimating by region, state, or local jurisdictions. NEISS data
are based solely on information provided in the ED record and are not linked to
criminal justice, police, or other data sources to supplement or verify information regarding
the intent of injury. Also, information regarding locale where the injury occurred,
victim-offender relationship, and type of firearm involved was missing for approximately
half of the NEISS cases. Limitations occur also in using NVSS data to examine
fatal firearm-related injuries. NVSS data are based on information recorded on
death certificates. Data on victim-offender relationship are rarely recorded. Space
is provided on the death certificate to record locale
where the injury occurred and type of firearm used, but these items might not be recorded.

Public health efforts through surveillance, research, and prevention programs
need to be expanded to further reduce firearm-related injuries. Efforts are under way
to improve the availability of surveillance data on firearm-related injuries. CDC
is collaborating with other public health organizations and federal agencies to
implement the National Violent Death Reporting System, which will include information on
all homicides and suicides, as well as all firearm-related deaths of known
and undetermined intent. Only basic national- and state-level data are available
regarding firearm-related deaths and injuries on which to base policies and practice. The
benefits of a state-based, national reporting system to track the incidence and characteristics
of a health condition have been well-established in other areas (e.g., infectious
diseases and motor-vehicle safety). As a result, the Institute of Medicine has recommended
a national data system for homicides and suicides that would provide objective data
with which to monitor trends and evaluate the effectiveness of prevention programs
and policies (17). Additionally, with funding from five private foundations, the
Harvard Injury Control Research Center (HICRC) has launched the National Firearm
Injury Statistics System (NFISS). HICRC is collaborating with the Medical College
of Wisconsin, state and local grantees (i.e., Connecticut, Maine,
Maryland, Michigan, Utah, and Wisconsin; and locally in Allegheny County [Pennsylvania],
metropolitan Atlanta [Georgia], and San Francisco [California]); and others to design and pilot
firearm-related injury-reporting systems at the state and local levels. NFISS builds on a
model developed by the Medical College of Wisconsin and draws from four major
reporting sources: death certificates, coroner/medical examiner reports, police
supplementary homicide reports (and, in certain jurisdictions, incident reports), and crime
laboratory data. NFISS collaborators have developed uniform data elements for fatal
firearm-related injuries, which are detailed in a manual, and the software architecture for
the system (18).

The overall percentage decline in fatal and nonfatal firearm-related injury rates
in the U.S. population during 1993--1998 is consistent with a 27% decrease in
violent crime during the same time period
(19). Since 1950, unintentional fatal
firearm-related injury rates have declined. NEISS data also indicate a decline since 1993 in the rate
of nonfatal unintentional firearm-related injuries treated in hospital EDs. The majority
of these nonfatal injuries occurred among males aged 15--44 years, were
self-inflicted, and were associated with hunting, target shooting, and routine gun handling
(i.e., cleaning, loading, or unloading a gun)
(4). Additional investigations should focus
on factors that might have contributed to the decrease (e.g., gun safety courses
and information campaigns, the proportion of the population that uses guns
for recreational purposes, and legislation).

Certain factors might have contributed to the decrease in both fatal and
nonfatal assaultive firearm-related injury rates. Possible contributors include improvements
in economic conditions; aging of the population; decline of the cocaine market; changes
in legislation, sentencing guidelines, and law-enforcement practices; and
improvements associated with violence prevention programs
(20). However, the importance and relative contribution of each of these factors have not been determined, and
the reasons are not known for the declines in firearm-related suicide and suicide
attempt rates.

Research to understand the trends in firearm-related homicides and injuries
from assaults has focused on the role of the lethality of firearms, demographic
changes, economic factors, imprisonment, and drug markets
(20). Each of these factors might have played a role in the increases in firearm-related homicides occurring before
1993 and the declines, documented in this report, since that time
(20). Research is needed to understand factors that contribute to racial and ethnic disparities in fatal and
nonfatal firearm-related injuries and to identify prevention efforts to reduce these
disparities. Evaluations of policies and programs that have the potential to further decrease
these injuries are needed (21).

Acknowledgments

We express our appreciation to the following CDC staff: Daniel M. Sosin, M.D.,
M.P.H., Jennifer H. Madans, Ph.D., and Lois A. Fingerhut, M.A., for their helpful review
and comments; Patricia Holmgreen, M.S., and Kevin W. Webb for computer
programming assistance; and Marilyn L. Kirk and Mary Ann Braun for preparing the figures. We
also express appreciation to Arthur K. McDonald, M.A., Director, and Thomas J. Schroeder,
M.S., Statistician and Project Officer, Division of Hazard and Injury Data Systems; and other
staff of the U.S. Consumer Product Safety Commission for their diligence in providing
high-quality surveillance data regarding nonfatal firearm-related injuries by using the
National Electronic Injury Surveillance System.

Davis Y, Annest JL, Powell KE, Mercy JA. Evaluation of the National Electronic
Injury Surveillance System for use in monitoring nonfatal firearm injuries and obtaining
national estimates. Journal of Safety Research 1996;27:83--91.

** On the ED record, frequently, only one entry is available for race or ethnicity,
not for both. The classification scheme used in this report assumed that most
white Hispanics were likely to be recorded on the ED record as Hispanic and most
black Hispanics were likely to be recorded as black.

***Semiannual rates, rather than quarterly rates, were used for trend analysis of
firearm-related suicides and suicide attempts because of the limited number of nonfatal
firearm-related suicide attempts.

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